A Basic Primer On Vertebral Fracture Assessment (VFA)

Andrew Laster, MD, FACR, CCD
Public Policy Committee Chair

WHAT IS VFA?
Vertebral Fracture Assessment (VFA) is a new technology using central DXA that permits imaging of the thoracic and lumbar spine to evaluate for the presence of vertebral fractures. Images can be obtained at the same time as a BMD measurement at lower cost and radiation exposure than plain radiographs of the spine.

WHY IS VFA IMPORTANT?
Identification of prevalent vertebral fractures is felt to significantly improve the management of patients with osteoporosis:

  • Patients with prevalent vertebral fractures are at increased risk for future osteoporotic fractures of the spine, wrist and hip.
  • 2/3rds of patients with vertebral fractures are asymptomatic, so patients often do not present with complaints of back pain.
  • Up to 40% of patients who have osteoporotic vertebral fractures have BMD values that are better than -2.5, the WHO established definition for osteoporosis in post-menopausal women measured by central DXA.
  • Prior vertebral fractures are a better predictor of future fracture than low BMD alone
  • Patients with prevalent vertebral fracture demonstrate a greater response to medical therapy than patients without prior fracture.

WHAT ARE THE INDICATIONS FOR VFA?
Unlike DXA testing where indications for testing were legislated in the Bone Mass Measurement Act (BMMA), consensus on indications for VFA have not yet been established. This has resulted in disparities in insurance coverage (see below).

Based on a review of the literature, the VFA Task Force has noted that vertebral fractures occur most commonly in the following settings:

  • Age (women greater than or equal to 65 yrs and men greater than or equal to 70 yrs)
  • Known height loss of greater than or equal to 1.5″
  • History of vertebral fracture after age 45
  • BMD evidence of osteoporosis at the hip or spine
  • Corticosteroid use (greater than or equal to 5 mg/day for greater than or equal to 3 months)

VFA would be of particular value in settings where knowledge of prior fracture would alter treatment outcome. Since, some individuals with T-scores between -1.0 and -2.5 might not be otherwise treated if their short term fracture risk was low, the identification of a vertebral fragility fracture would “make” the diagnosis of osteoporosis and lead to medical therapy. The literature clearly supports treatment benefit in this setting.

In cases where the health care provider has already decided to initiate medical therapy (for example based on T-scores below a critical threshold), VFA might be of less value. Similarly, in those with normal bone density (T-scores of -1.0 or better) and not on corticosteroids, the identification of a vertebral fracture does not clearly prove the presence of osteoporosis nor does the literature provide guidance as to the most appropriate medical therapy.

The ISCD Position Development Conference to be held in Vancouver in July will review Task Force suggestions and hear public commentary. Final recommendations regarding indications should follow shortly thereafter. Hopefully, this will assist in insurance coverage for VFA.

WHERE CAN ONE LEARN MORE ABOUT VFA?
An introductory PowerPoint presentation on VFA is available on the Resources page of this Web site. A 1 hour overview of VFA is now part of each ISCD Bone Densitometry course. In addition, an in depth 4-hour course on VFA is now being offered by the ISCD. (Visit Upcoming Courses page for course dates and locations).

CPT CODE AND COVERAGE ISSUES
On January 1,2005 a new CPT code, 76077, for VFA was introduced. A number of insurers have been reimbursing for VFA (national average Medicare rate is $41). The largest number of denials have come from state Medicare carriers and Blue Cross/Blue Shield (BC/BS).

The reasons for denial differ with the BC/BS Medical Advisory Panel arguing that VFA fails to alter treatment outcomes beyond information gained from DXA and clinical risk factors alone. In contrast, it appears from postings on the Centers for Medicare and Medicaid Services (CMS) Web site that many of the state Medicare carriers mistakenly believe that code 76077 incorporates both central DXA and VFA rather than distinguishing between the two.

Blue Cross/Blue Shield Position on VFA:
On October 26, 2004 the Blue Cross and Blue Shield (BC/BS) Medical Advisory Panel (MAP) met to review a report of VFA prepared by its Technology Evaluation Center (TEC). The findings of this evaluation were published in December 2004 (Assessment Program Vol 19; No 14). They concluded that VFA did not meet specific TEC criteria with the inherent assumption that health care providers would not be reimbursed for performing VFA in patients covered by BC/BS.

The MAP agreed that 3 of the 4 critical assumptions needed to prove that VFA would have an effect on health outcomes had been met based on their review of the available literature. These included:
1. “prevalent vertebral fractures predict future osteoporotic fractures”
2. “vertebral fracture assessment identifies additional patients who are potential candidates for pharmacologic treatment based on presence of fracture”
3. “vertebral fractures are accurately identified with vertebral assessment using DXA”

Evidence supporting the fourth assumption “patients identified (by VFA) benefit from pharmacologic therapy” was felt to be lacking. “There is a lack of clinical trial evidence showing that patients with vertebral fractures but with bone mineral density levels above treatment thresholds benefit from therapy”. In the Executive Summary this conclusion was restated but in a different form: “…there is no evidence showing that treatment decisions based on joint determination of bone mineral density and vertebral assessment using DXA result in better patient outcomes than the usual method of clinical risk factors and measurement of bone mineral density.”

The ISCD has written a letter of rebuttal and argued that there is good scientific evidence demonstrating that patients identified by the presence of vertebral fracture with BMD values above the treatment threshold benefit from medical therapy. Additionally, patients identified by the presence and grade (severity) of prevalent vertebral fracture regardless of their BMD demonstrate improved outcomes to medical therapy. BC/BS has indicated that they will review the additional evidence presented by ISCD.

CMS Position on VFA:
Among Medicare carriers, six states currently reimburse for VFA. These include New York [excluding upstate NY and Queens] (Empire), Wisconsin (Wisconsin Physician Services), North Carolina (CIGNA), Tennessee (CIGNA), Texas (Trailblazer) and Ohio (Palmetto). The indications for VFA testing vary among these different carriers with some adopting the same ICD-9 codes as instituted by the Bone Mass Measurement Act for DXA testing while others have restricted coverage to specific diagnostic codes related to vertebral fracture identification.

If you practice in a state where the Medicare carrier covers VFA and it is not listed here, please notify your regional public policy representative.

VFA, Future Directions
As noted above, the ISCD has appointed a VFA Task Force that is busy preparing recommendations for consideration at the Position Development Conference in Vancouver, B.C. in July. Following public commentary, the ISCD should finalize its official position on indications for VFA testing.

The ISCD is committed to assisting members in obtaining coverage for VFA. Please contact your regional public policy representative if you are aware of other major carriers that are not reimbursing for VFA at this time.

Last modified: December 17, 2012